ACA Cost-Sharing Could Limit Rx Access: PhRMA

Enrollees in some of the health law's most popular plans will face high cost-sharing requirements that the pharmaceutical industry says could keep patients from getting the drugs they need.

Most silver plans in the online marketplaces, or exchanges, require patients to pay for prescription drugs as part of the plan's deductible, while nearly all bronze plans do, according to a report from Breakaway Health prepared for the Pharmaceutical Research and Manufacturers of America (PhRMA), the drug industry's trade group.

Silver plans that combine prescription and medical costs into one deductible -- the out-of-pocket costs patients pay before coverage begins -- have average deductibles of $2,275, and similar bronze plans have an average of $4,986, according to the report. The average amount for plans that have separate prescription drug deductibles is $470 for a silver plan and $956 for a bronze one.

For a typical employer-sponsored health plan, on average people pay about 22 percent of the cost of prescription drugs and their insurance covers the rest, said John Castellani, who heads PhRMA. According to the analysis done for the association, the health law's bronze and silver plans require more than twice that amount. (Platinum and gold plans on the exchange generally have lower cost-sharing requirements but charge higher premiums.)

Of course, this isn't the first time concerns have been raised about the affordability of coverage offered by the health law's exchanges. Analysts and consumer groups, among others, have expressed fears that "sticker shock" on premium prices in some areas might discourage people from enrolling in coverage or, once enrolled, high cost-sharing requirements for deductibles and copays could discourage people from accessing care when they need it.

But Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, offered a different take. He said in a statement that, before the health law, "plans did not have to cover drugs, and consumers could face unlimited out-of-pocket expenses for plans with limited benefits and high deductibles, if they could even get coverage without being denied for a pre-existing condition." With the health law now in place, "prescription drugs are covered, out-of-pocket expenses are capped, and there are no denials based on health, among other consumer protections."

In an interview, Castellani said that higher cost-sharing requirements for the law's silver and bronze plans are "a concern for us from the patient standpoint, obviously, because you're disincentivizing patients, particularly patients with chronic diseases, to continue to manage their chronic disease in exchange for what was a political imperative, which was a low premium, as low as possible," he said. "Yet their out-of-pocket expenses are potentially so high that we have to be concerned about whether or not people will be able to afford to continue to get their medicines."

The average cost-sharing "tiers" for prescriptions on the bronze and silver plans are also higher than employer-sponsored plans, according to the report. For example, average copays for employer sponsored insurance for specialty drugs are $80, compared with $159 for silver plans and $157 for bronze, it notes.

Some of those costs may be mitigated by the law's cost-sharing subsidies for silver plan enrollees whose incomes are up to 250 percent of poverty (about $28,725 for an individual, higher for families), with the assistance greatest for those at the lower end of the income scale. Those subsidies reduce the deductibles and other out-of-pocket costs people are required to pay. Insurers have some flexibility on how that cost-sharing is reduced but the plans must meet specific actuarial values. The cost-sharing subsidies do not apply to other plans sold on the exchanges.

Insurers can exclude some medications, like generics, which account for 86 percent of all drugs dispensed, from a deductible but still require other cost-sharing. The more expensive the drug, however, the more the consumer usually pays out of pocket.

Castellani said PhRMA has brought its concerns to the health insurance industry, to the Department of Health and Human Services, and to patient groups, among others.

Clare Krusing, a spokeswoman for America's Health Insurance Plans, a trade group representing insurers, said the problem is that drug prices are too high.

"Research shows that drug prices continue to soar and are one of the leading drivers of healthcare cost increases. Any discussion of prescription drug coverage must also include a focus on the direct link between rising prescription drug prices and consumer cost-sharing," she said in a statement. "Rising prices for prescription drugs put a financial burden on patients by forcing them to pay for these cost increases through higher premiums or increased out-of-pocket costs."

This article, which first appeared May 7, 2014, was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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